Developing Community Partners for Population Health Management

Community partners and socioeconomic services are vital for primary care providers looking to succeed with population health management.

October 19, 2017 - Whether they are participating in value-based reimbursements or still based in fee-for-service, the vast majority of primary care providers are keenly aware that they can no longer afford to go it alone.

Consumer expectations are changing, regulatory frameworks are demanding exceptional quality scores, and organizations that have made the leap into risk-based financial arrangements are putting pressure on their partners to help them achieve their outcomes-based goals.

Alongside the proliferation of health IT tools that have created the potential (if not yet the reality) of a free-flowing big data environment, these seismic shifts in the healthcare environment are starting to turn population health management competencies into a fundamental necessity.

Risk stratification tools, data interoperability, clinical decision support, and predictive analytics are important pieces of the population health puzzle – but so are the lower-tech skills of forming strong partnerships with complementary providers within the community.

Creating a coordinated, accessible, and comprehensive safety net for patients with complex needs or rising risks is an essential component of successful population health management.

From dental services and pharmacists to social support and urgent care options, primary care providers can and should collaborate with a wide variety of stakeholders to ensure that patients are receiving the holistic, proactive care that will help them avoid unnecessary spending and adverse health events.

Non-adherence is a $337 billion problem which is exacerbated by patient forgetfulness, confusion, and procrastination. Nearly 70 percent of non-adherence is driven primarily by these patient behaviors, Express Scripts found in 2015, which may lead to preventable hospitalizations and increased utilization.

Tapping pharmacists as an additional touch point for patients can improve education and ensure that individuals understand their regimens.

Pharmacists are trained to educate consumers about the impact and potential side effects of their medications, yet they are severely underutilized, even in many coordinated care settings.

A 2016 report by the Pharmacy Benefit Management Institute found that only 57 percent of accountable care organizations are contracted with clinical pharmacists, despite more than 93 percent of ACOs affirming that population health management is among their primary goals.

Pharmacists can also help simplify complicated regimens by offering medication synchronization, which allows patients to pick up all of their medications during one trip to the pharmacy. For patients with mobility difficulties or a high number of prescriptions, this can be a significant lifestyle benefit.

One collaboration between the University of Pennsylvania and Humana found that synching medications raised adherence by up to 13 percent for common chronic conditions such as diabetes and hypertension.

Streamlining the medication acquisition process while engaging pharmacists to provide meaningful patient education and guidance, even before they leave the hospital after an acute event, can create improved adherence rates that improve outcomes while saving measurable dollars.

Behavioral and mental healthcare

The importance of adequately and proactively addressing behavioral and mental health issues cannot be overstated.

Psychological distress and depression reduce quality of life just as much or more than having a chronic disease, said a 2016 study published in Quality of Life Research.

Chronic unsolved pain had a similarly negative effect on patient outlook – an important consideration in light of the raging opioid epidemic.

Co-location of primary and mental healthcare services, or a robust referral process to partner provides including follow-up from the PCP, can help to connect patients with the sources they need.

When primary care providers in Colorado collaborated closely with co-located mental healthcare providers, close to a third of patients saw at least a 50 percent improvement on the standardized Patient Health Questionnaire (PHQ-9) assessment.

PCPs in one of the many regions experiencing a shortage of behavioral and mental health service providers may also explore the use of mobile applications and online tools to supplement their offerings.

One mobile health application in use at Mount Sinai Hospital helped reduce symptoms in patients with major depression by 42 percent, a recent study showed. And telepsychology services are now on offer from a number of remote consult services such as American Well, Teladoc, and MDLive.

Community care, social work, and child welfare services

The socioeconomic determinants of health are often more impactful to patients than the clinical care they receive. As a result, it is increasingly important for provider organizations, especially those financially responsible for overall outcomes, to extend their reach into the community.

Partnering with public health departments, social workers, child welfare officers, and community service organizations can help PCPs address socioeconomic issues including domestic abuse, housing instability, unemployment, low literacy rates, and nutrition concerns.

Partnerships within the community can take many forms. In rural Nebraska, McCook County Hospital dispatches paramedics on home visits for the recently discharged to ensure that excessively long drives back to the hospital for follow-up do not contribute to avoidable readmissions.

In Baltimore, Bon Secours Health System coordinates efforts to connect individuals with affordable housing and job training. And Nationwide Children’s Hospital in Ohio established the Healthy Neighborhoods, Healthy Families project to develop safer neighborhoods, enhance access to quality education, and develop the local workforce.

Regions that invest in strategic community partnerships and build a culture of health outside of the walls of the clinic tend to reduce downstream clinical costs, notes a recent study from the Robert Wood Johnson Foundation.

A 20 percent increase in the median social-to-health spending ratio was equivalent to 85,000 fewer adults with obesity and more than 950,000 adults with mental illness at the state level, which adds incentive for providers to contribute to greater socioeconomic stability in their communities.

Dental care and oral hygiene

Dentists have traditionally operated outside of the clinical care continuum, in part because of the practice of insuring dental and clinical care separately. But oral health and hygiene play an important role in overall health, and are often key factors in the development of chronic diseases.

Dental pain is also one of the top reasons why patients visit the emergency department, according to a study from the International Journal for Quality in Health Care, driving up costs in a setting that typically cannot provide appropriate treatment.

Disparities in access to dental care often fall along racial, ethnic, and economic lines, notes the Healthy People 2020 Project. Only 27.6 percent of patients living below the federal poverty line say they saw a dentist in 2013, compared to 55.5 percent of those above 400 percent of the poverty line.

Increasing access to affordable dental care can improve the likelihood of identifying throat and oral cancers earlier and reduce the long-term health impacts of destructive periodontal diseases and infections that begin in the mouth.

Untreated dental pain may also drive some patients to improper use of opioids. Closely collaborating with dentists to treat pain correctly – and share some of the best practices for appropriate opioid prescriptions being developed in the clinical environment – may prevent patients from falling into negative behavioral patterns.

Retail clinics and urgent care providers

Many population health management frameworks, including the patient-centered medical home (PCMH), encourage PCPs to offer expanded hours and after-hours helplines for patients.

But most primary care providers cannot operate around the clock, leaving patients with the choice of waiting until they can get an appointment, going to the nearest emergency room, or seeking out an urgent care center or retail clinic.

The latter is often the most cost-effective and appropriate for minor to mid-level complaints that emerge on the weekends or after office hours, but many patients are unaware of how to decide where to seek care.

A 2017 survey by urgent care provider CityMD found that only about half percent of patients would choose urgent care over the ED for a variety of common situations, including a child with a high fever, a deep laceration, or a significant nosebleed.

Unambiguously serious situations, including loss of consciousness after an accident or heart attack and stroke symptoms, led the vast majority to opt for the emergency room, indicating that there is an opportunity for primary care providers to help patients understand where to draw the line.

While many urgent care centers are owned and operated by companies that focus exclusively on the segment, more and more hospital systems are opening up these outlets to complement their traditional services. This allows health systems to capture the revenue from lower-level complaints without spending extraneous resources through their full-scale emergency and trauma centers.

This integration also allows patient information to stay within a single health network, which facilitates follow-up from PCPs or appropriate specialists after an urgent visit.

Forming partnerships with a community’s urgent care locations or opening facilities under the control of a parent provider can streamline information sharing and enhance care coordination.

Retail clinics, which offer basic health maintenance services such as flu shots alongside care for issues within the scope of nurse practitioners or physician assistants, are addressing the care continuum issue in a slightly different manner.

Two of the major retail health chains, CVS Health and Walgreens, have adopted Epic Systems electronic health records and population health management technologies to support their integration into the traditional care process.

With an emphasis on coordinating with primary care providers to ensure continuity, retail clinics equipped with top-shelf technologies are important partners for boosting immunization rates, enhancing care access, and offering patients more options without overwhelming PCP appointment calendars.

Whether or not retail and urgent care clinics truly lower ED spending is up for debate, but the convenience factor for patients who might otherwise ignore emerging concerns is undeniable.

Adding more options for patients to receive an appropriate level of care at several different locations within their communities may help to support an overall population health management approach that takes a proactive stance towards caring for individuals.

If primary care providers can successfully extend their influence to patients in their own homes, schools, and workplaces through more robust partnerships with community organizations, they may be able to raise satisfaction while achieving better outcomes and lowering costs.